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Concussion management: A comprehensive course for the

return to life, sport, and work

MIKE STUDER, PT, MHS, NCS, CEEAA, CWT, CSST

Provider Disclaimer

• Allied Health Education and the presenter of this

webinar do not have any financial or other

associations with the manufacturers of any products

or suppliers of commercial services that may be

discussed or displayed in this presentation.

• There was no commercial support for this

presentation.

• The views expressed in this presentation are the

views and opinions of the presenter.

• Participants must use discretion when using the

information contained in this presentation.

OUTLINE

Course outline, content and objectives

Epidemiology and neurophysiology of concussion

Unique attributes and common symptoms of sport-related concussion

Early mobilization and the role of exercise

Treatment of hypersensitivity, imbalance, dizziness

Treatment of migraine, cervical pain, fatigue

Treatment of attention: dual and multi-tasking: visual, auditory, motor, and cognitive

Return to life, sport, and work

Case studies: Application to your practice

Questions, discussion

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What is a concussion?Physiology: immediate or delayed changes in the brain's chemistry and function (does NOT require observable change on imaging).

Concussion is a traumatic brain injury that can damage brain tissue and change the chemical balance of the brain. Concussion may cause physical, mental, and emotional symptoms and problems, both short-term and long-term. Every concussion is considered a serious injury by health care providers.

A concussion IS a brain injury!

Epidemiology and effectsThe Centers for Disease Control (CDC) estimates that 2.5 million concussions occurred in the United States in 2010, the most recent year for which the CDC has statistics.

•32% of parents have fear that their child will be concussed

1 in 4 parents forbid their children to play some contact sports due to fear

> 300,000 concussions/year in H.S. sports; > 135,000 in work and life

Between 2001 and 2005, more than 225,000 pediatric ER visits due to sport related concussion

1 in 4 individuals over 65 fall each year

High School Concussions

Football (47.1%)

Girls’ soccer (8.2%)

Boys’ wrestling (5.8%)

Girls’ basketball (5.5%)

Football had the highest concussion rate (6.4)

Boys’ ice hockey (5.4)

Boys’ lacrosse (4.0)

Concussions = 22.2% of total injuries in boys’ ice hockey

All other sports studied (13.0%)

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Epidemiology of Concussion1.6 to 3.8 million concussions occur in sports and recreational activities annually (CDC)

> 300,000 concussions/year in H.S. sports

Falls, MVAs, assaults are next by cause

US Department of Defense reported 253,349 mild TBI cases between 2000 and 2014

2001-05, > 500,000 pediatric ER visits. ½ sport related

After one concussion 1.5x, two concussions 2.8x, and three or more prior concussions 3.4x (likelihood of increased risk)

Mechanisms of concussionConcussions can occur at any age, from a variety of causes, including:

Car accidents (ie, a head impact, or whiplash)

Work accidents (ie, falls, head trauma)

Playground accidents (ie, falling from a slide or swing)

Sports injury to the head or neck

Any type of fall or direct blow to the head, face, or neck

Consensus Statement on Concussion in Sport: Definition and mechanisms

1. Concussion may be caused by a direct blow to the head, face, neck, or elsewhere on the body with an “impulsive” force transmitted to the head. *can occur with whiplash and coup/contrecoup mechanism

2. Concussion typically results in the rapid onset of short-lived impairment of neurologic function that resolves spontaneously. However, in some cases, symptoms and signs may evolve over a number of minutes to hours.

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Consensus Statement on Concussion in Sport: Definition and mechanisms

3. Concussion may result in neuropathologic changes, but the acute clinical symptoms largely reflect a functional disturbance rather than a structural injury, and as such, no abnormality is seen on standard structural neuroimaging studies.

4. Concussion results in a graded set of clinical symptoms that may or may not involve loss of consciousness. Resolution of the clinical and cognitive symptoms typically follows a sequential course. However, it is important to note that in some cases symptoms may be prolonged.

Concussion: Prognosis modifiersNumber of symptoms

Symptoms remaining at 24 hours

Convulsions

History of concussions AND any concussion in the past 7 days

Age 18 or younger; Age 70 and older

History of: migraine, depression, ADHD, prior concussion, sleep disorder

Psychoactive medications or anticoagulants

Style of play (aggressive)

Sport and position: high risk/incidence

ImagingMRI

Diffusion tensor imaging

Transcranial Magnetic Stimulation

Magnetoencephalography

Electroencephalography

fMRI - prognostics

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Neurophysiology of Concussion

Impact - mechanically-induced depolarization

Neurotransmitters – decreased glutamate

Circulation and inflammation = susceptible to hypoxia

Learned non-use and hypersensitivity

Boyd, 2015 JNPT

Neurophysiology of Concussion

Sudden mechanical loading of the head may generate turbulent rotatory and other movements of the cerebral hemispheres and so increase the chances of a tissue-deforming collision or impact between the cortex and the boney walls of the skull.

Deafferentation of the cortex as a consequence of diffuse mechanically-induced depolarization and synchronized discharge of cortical neurons.

Shaw EA, 2002

Acute signs•Vacant stare

•Delayed verbal expression (slower to answer or follow instructions)

•Inability to focus attention (distractible)

•Disorientation (walking in wrong direction, unaware of time/day/place)

•Slurred or incoherent speech

•Gross observable incoordination (stumbling, unable to tandem walk)

•Emotional lability

•Memory deficits

•Any period of loss of consciousness

•Nausea or vomiting

•Headache

•Dizziness

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Diagnosis-specific considerations: ExaminationConcussion

Processing speed, intolerance of stimuli

Manifested as symptoms of:

nausea headaches

blurred vision dizziness

imbalance pressure/fogginess

Diagnosis-specific considerations: ExaminationObjective on-field and clinic exams:

SCAT-5

IMPACT

BESS + CTSIB/Isway

DUAL TASK COST*

*Presently being studied for immediate and latent exams

Diagnosis-specific considerations: ExaminationIn clinic exams:

Posturography

CTSIB/Isway

DUAL TASK COST*

Mental status (MMSE, SLUMS, etc)

FGA: Functional Gait Assessment

DHI: Dizziness Handicap Index

CIF Graded symptoms (California Interscholastic Federation)

*Presently being studied for immediate and latent exams

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Persistent symptoms

•Cognitive impairment (memory, attention, concentration,

reaction time)

•Headache (with/without migraine component)

•Difficulty with balance

•Dizziness

•Difficulty focusing or reading

•Fatigue

Persistent symptoms

•Photosensitivity

•Fogginess

•Feeling slowed down (bradyphrenia)

•Mood disruption (irritable, nervous, depressed)

•Amnesia (retrograde or anterograde)

•Sleep disturbance (inadequate or excessive)

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Early stage management: rehabilitative handling after concussion

•Light activity earlier = better

•Sufficient and INTERESTING stimuli - recognize goal/error

•More active patient involvement – providing feedback

•Introduce dual tasking at the right time (Stage #3)

•Measure your results!

•Allow for success, enjoyment, return to norm, + satisfaction

Stages of recovery: (5)Rest and precaution* (now no greater than 48 hours)

Aerobic activity, light. Reduce headaches and sensitivities to stimuli + movement

Restoring physical and cognitive endurance + sport-specific exercise

Returning to non-contact training/drills in sport + increase cognitive load

Full contact practice/return to sport

Rehabilitation Stage Therapeutic Exercise Objective Considerations

Stage 1: Light and intermittent activity (UPDATE NO > 48hr)

Daily mobility Recovery Limit stimuli and stressors

Stage 2: Light aerobic exercise *

•Walk, swim, bike intensity <70% HR•No resistance

Increase heart rate and reduce sequelae

Treat headaches, dizziness, and light intolerance, etc.

Stage 3: Sport-specific exercise

•One-player drills•Return to running•No head impact

Add movement,confidence, dynamic balance + kinesthesia

Limit dual taskIntermittent

Stage 4: Noncontact training drills

•Dual task drills + agility•Catching, tracking• Resistance training

Increase exercise, coordination, and cognitive load

Investigateexertional responses

Stage 5: Full-contact practice

Normal and full-speed training activities

Restore confidence and assess game readiness

Psychology of return (coach, player, team, parent)

*MODIFIED FROM: McCrory P, et al Consensus statement on concussion in sport: the

4th International Conference on Concussion in Sport. Br J Sports Med. 2013

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Stages of recovery: (1)Rest and precaution - no greater than 48 hours

REDUCE:

Screen time of all kinds: TV, phone, computer, gaming

Artificial light exposure

Noise

Pressure/distractions

Debunking the bunk-ing…(bedrest)

"Recommending strict rest from the ED did not improve symptom, neurocognitive, and balance outcomes in youth diagnosed with concussion," authors write. "Surprisingly, adolescents who were recommended strict rest after injury reported more symptoms over the course of this study.“

Thomas DG, Apps J. Benefits of Strict Rest After Acute Concussion: A Randomized Controlled Trial. Pediatrics Jan 2015

Concussion: symptom management

Prolonged

bedrest is not a

treatment for

concussion

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Rest – amount and advice • Avoid daytime naps

• Regular circadian cycle of wake and bed times (individual, pre-injury)

• Relaxation strategies (again, individualized WITHOUT overstimulation)

• Restrict caffeine and other stimulants for wakefulness

• Limit stimulating physical activity just prior to sleep

•Berlin 2017* – 24 to 48 hours

Concussion: symptom management

•Stimuli intolerance: sound, light, overload

•Headaches, migraines and blurred vision

•Dizziness and imbalance

•Attentional interference, distractability

•Deconditioning

Stages of recovery (2)Reducing headaches and sensitivities to stimuli or movement

Cervical intervention

Gradual re-exposure: light, sound, movement (habituation)

General exercise without risk (no free weights or balance needed). Consider aerobics and sport specifics.

Oculomotor and vestibular programming: dizziness, imbalance

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Intolerance of stimuli•Visual

•Auditory

•Psychological

•Physical – resistance, endurance, impact

•Life stressors (environmental or self imposed)

•Task-specific (cognitive demand, dual/multi task)

Rebuilding tolerance

•Light/sound

•Cognitive

•Psychological

•Activity

HeadachesDetermine the origin and treat the cause:

• Exertion: Begin light and test Modified Balke

• Stimuli: Visual, auditory, cognitive, psychological

• Musculoskeletal/mechanical: cervicogenic, other

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Headaches Determine the origin and treat the cause:

•Compensation for dizziness/imbalance

•Nutritional/hydration

•Sleep

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Blurred vision•Investigate vestibular integration (VOR, DVA)

•Investigate cervical stability, endurance

•Rehabilitate with vision therapy using principles of neuroplasticity, adaptation*

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DizzinessVestibular habituation techniques work. Why?

Processing speed

Integration of signals

Proximity/interconnected “Vestibular cortex”

Neuroplasticity

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Imbalance•Static and quickly to dynamic

•Limit visual distractions during rehab

of balance, re-integrate later

•Sport specific and person specific = interest

•Reduce visual dependency in neuroplasticity

(early tendencies to rely solely on vision)

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Stages of recovery (3)Restoring Strength, Physical and Cognitive Endurance

Reversing deconditioning (physical and cognitive)

Restoring kinesthesia, gradually sport-specific

Monitoring return of ANY symptoms with exertion

Limited intensities

Best delivered in intervals with rest periods

Begin dual task introduction

Consider nutrition and hydration (patient less-likely to do so)

Physical Re-conditioningPatients with refractory postconcussion symptoms and measured the effects of controlled exercise, specifically SUBSYMPTOM THRESHOLD EXERCISE TRAINING (SSTET).

After SSTET, subjects could exercise longer (pretraining exercise duration 9.8 minutes, posttraining 18.7), with higher peak heart rate (147 pretraining versus 179 posttraining) and systolic blood pressure (142 pretraining versus 156 posttraining) AND without symptom exacerbation.

Johnson L1, Burridge JH, Demain SH.Internal and external focus of attention during gait re-education: an observational study of physical therapist practice in stroke rehabilitation. Phys Ther. 2013 Jul;93(7):957-66.

Fatigue: Cognitive and physical1) CONSIDER WHAT (sport, activity) we are returning them to….

2) Remember that we need to rebuild physical and cognitive loading

3) Too much protection/rest/precaution = learned non-use; hypersensitivity rebound AND psychological impact (depression)

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Standardizing the exertion “dosage”Modified Balke Protocol: The modification of Balke consists of nine stages per 1 min at a constant velocity of 3.5 mph and increasing elevation from 6% to 22% in 2% increments

Buffalo Concussion Treadmill Test (3.6mph at 1% incline and progressing 1%/minute to tolerance (exertion or symptom-onset)

Rate perceived exertion

Rate symptoms

Attentional interference

Dual task rehabilitation considers:

•Mode of distraction this person needs

•Exertion of the primary task

•Symptoms of overload (headache, dizziness, nausea) for this person

•Progression toward multi-tasking

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How does a task become (and stay) automatic?

•Thousands of repetitions

•Forced dual tasking with practice (later)

•Focusing on the retraining/repetitions AND the ability to inhibit distractions

What tasks and functions are automatic?

•Walking

•Dressing

•Brushing your teeth

•Typing

•Driving

•Communication (non verbal cues)

Why and HOW are these tasks automatized?

•Thousands of repetitions

•Forced out of conscious processing

•Dual tasking as a function of life/choices

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What does everyday movement AND SPORTS require?

•Automatic motor operations

•Overlay of internal thoughts

•Interaction with environmental motion

•Planning the next movements

Modes of dual tasking•Cognitive – internal thought

•Auditory – sound (verbal or otherwise)

•Visual - peripheral or central distractor

•Manual – handling (hands or feet)

Visual•Glare

•Sudden movement in visual field

•Phone, texting

•Media

•Conversational eye contact

•Environmental (not relevant to the task)

•Lamellar flow (traffic, walking, running) in your peripheral visual field

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Manual•Task-related with manipulation

Phone

Wallet/purse

Toothbrush, medications

•Functional/gross motor: carrying clothes, plate, cup

•Work specific

•Sport-specific manipulation of ball, bat, stick, glove

Dual Task TestingObjective examination of each mode of attention, progressively in the context of:

I. Balance (static)

II. Mobility (dynamic balance)

III. Work/Sport (task-specific mobility distractions)

Parameters of Attention

•Focused – amount/vigilance

•Sustained – duration

•Divided – simultaneous two or more

•Alternating – switching

•Selected – filtering

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Tests that measure attention (and executive functioning)•SLUMS (St Louis Univ Memory Scale)

•Trail Making A and B

•MoCA

•Stroop

•Hayling Sentence Inhibition

•MMSE

•Mini-cog

© 2014, DR. ROB WINNINGHAM ALL RIGHTS RESERVED

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Demonstration

In a moment, you will see a list of words.

Please read the color the word is written in, not what the word says. Read the first column, then the second, then the third, and finally the fourth.

Example: RED say “Red”

Example: GREEN say “Red”

Please loudly state the color the word which is printed.

When you are done with all four columns, please raise your hand.

© 2014, DR. ROB WINNINGHAM ALL RIGHTS RESERVED

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© 2014, DR. ROB WINNINGHAM ALL RIGHTS RESERVED

© 2014, DR. ROB WINNINGHAM ALL RIGHTS RESERVED

Sentence Inhibition Activity

Instructions: Have participants verbally state a word that is different than the typical response, after you verbally state the first part of the sentence.

The captain will go down with the _____

Don’t judge a _____ by it’s cover

The early _____ gets the worm

Beauty is in the eye of the _______

© 2014, DR. ROB WINNINGHAM ALL RIGHTS RESERVED

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Measuring Attention

Use standardized, objective measures of function in concert with formal distractions

Test patient without distractions, record score

Test patient with distractions, compare score

Measuring Attention

Single task – Dual task x 100 = DTCost

Single task

Example: 40yd single = 5sec; distracted = 6.5 sec

5.0 – 6.5 sec x 100 = 30%

5.0 sec

Dual task overlay: mobilityTests lending themselves to dual task overlay:

•BERG

•TUGO

•4 square step test

•2 or 6 minute walk test

•Dynamic Gait Index

•Functional Gait Assessment

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Testing mobility with a cognitive distractor: in concussion

“…greater dual-task average gait speed costs were independently associated with prolonged symptom duration. Examinations of dual-task gait may provide useful information during multifaceted concussion examinations. Quantitative assessments that simultaneously test multiple domains, such as dual tasks, may be clinically valuable after a concussion to identify those more likely to experience symptoms for >28 days after injury.”

Howell DR The Association between Dual-Task Gait after Concussion and Prolonged Symptom Duration. J Neurotrauma. 2017 Oct 16.

*Most dual task research based in the elderly with vs. without cognitive loss

Functional dual task trainingWalking while:

•Pulling a kleenex from your pocket

•Retrieving an item from your purse

•Holding eye contact in conversation

•Buttoning a shirt

•Brushing teeth

•Donning clothes

Functional dual task trainingWalking while:

•Eating

•Adjusting glasses/cleaning

•Looking up a name in a phone book

•Reading the paper

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Balance and physical function•Computerized dynamic posturography

•Clinical Test of Sensory Interaction in Balance (CTSIB)

•Modified CTSIB

•Balance Error Scoring System (BESS Test)

Clinical Test for Sensory Integration in BalanceDetermining the relative contribution of sensory systems for balance organization. Eyes open/closed, surface stable/motion, surround is “sway-referenced” or not.

Computerized Dynamic PosturographyForceplate and visual surround with recorded sway for testing and training

May include CTSIB, reach, motor control, etc.

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Modified CTSIBFirm and Foam

Eyes open and Eyes Closed

*Often tested with feet approximated (nudge)

May have computerized monitor or scored by time

Balance Error Scoring System (BESS)Standardized balance performance test without posturographic assistance.

20 seconds/trial

Recording number of errors (out of static hold position)

Pre and post concussion

Testing BALANCE with a cognitive distractor: in concussion

“…two 2-min trials standing on a Nintendo Wii Balance Board™ during which the COP under their feet was recorded: i) double-leg stance, eyes open; ii) double-leg stance, eyes closed. Participants also completed a dual-task condition combining a double-leg stance and a Stroop Colour-word test.”

Rochefort C Self-reported balance status is not a reliable indicator of balance performance in adolescents at one-month post-concussion. J Sci Med Sport. 2017 Nov;20(11

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Testing BALANCE with a cognitive distractor: in concussion

“Adding a cognitive task during the tandem gait test resulted in longer detectable deficits post-concussion compared to the traditional single-task tandem gait test. As a clinical tool to assess dynamic motor function, tandem gait may assist with return to sport decisions after concussion.”

Howell DR . Single-task and dual-task tandem gait test performance after concussion. J Sci Med Sport. 2017

Return to school considerations•Sleep

•Transport/driving

•Size of class and distractions

•Examinations

•Expectations/AP

Return to work considerations•Sleep

•Transport/driving

•Responsibilities and safety of self/others

•Flexibility of schedule and breaks

•Examinations

•Expectations: meetings and information

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Returning to safety: automaticity and tolerance

Street crossing

Dual tasking in gait (texting, conversing, carrying objects)

Stairs/changes in surface

Passenger in a car

Driving…

Return to school considerations

•Partial attendance

•Late starts/early dismissals

•Rest periods during day

•Extra time for assignment completion

•Excuse from nonessential assignments

•Postpone or stagger testing

•Excuse from standardized testing

•Extra time and/or open book testing

•Examinations in small/quiet rooms

•Tutorial assistance

•Homebound instruction

•Excuse from gym and attendance in sport practices

•Excuse from assemblies, band/orchestra, woodshop

•Lunch in quiet area

•Accommodations for light and noise sensitivity (earplugs, ball cap, sunglasses, dimmer lights)

•Preferential classroom seating

•Books on tape

•Audiotaped lectures

•Provide notetaker or scribe

•Provide classroom notes or Powerpoint slides prior to class

Stages of recovery (4)Returning to Normal Activity or Sport

Programmed and task-specific grading:

Player movement

Ball manipulation/tracking

Speed of direction change/agility

Dual and multi-task considerations sport specific

Power/burst considerations

Education for preventing a second concussion

Rest and in-game rotation

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Rehabilitation Stage Therapeutic Exercise Objective Considerations

Stage 1: Light and intermittent activity (UPDATE NO > 48hr)

Daily mobility Recovery Limit stimuli and stressors

Stage 2: Light aerobic exercise *

•Walk, swim, bike intensity <70% HR•No resistance

Increase heart rate and reduce sequelae

Treat headaches, dizziness, and light intolerance, etc.

Stage 3: Sport-specific exercise

•One-player drills•Return to running•No head impact

Add movement,confidence, dynamic balance + kinesthesia

Limit dual taskIntermittent

Stage 4: Noncontact training drills

•Dual task drills + agility•Catching, tracking• Resistance training

Increase exercise, coordination, and cognitive load

Investigateexertional responses

Stage 5: Full-contact practice

Normal and full-speed training activities

Restore confidence and assess game readiness

Psychology of return (coach, player, team, parent)

*MODIFIED FROM: McCrory P, et al Consensus statement on concussion in sport: the

4th International Conference on Concussion in Sport. Br J Sports Med. 2013

Return to sport considerations•Speed of game and likelihood of impact

•Timeline of recovery/loss of conditioning

•Position changes/ability to rotate-out or limit impact

•Patient insight, safety, honesty, self-advocacy*

*Deubert CR, et al. Protecting and Promoting the Health of NFL Players. 2016.

Return to sport considerations

•ATC, parental and coaching support

•Patient history (# concussions)

•Tolerance + exposure to conditions in practice

•Duration and ambient conditions

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Return to sport considerations

•Rebuilding skill in a non-contact manner (ball handling, direction changes, impact of running, agility)

•Rebuilding confidence (post-traumatic stress) with psychological and physiological considerations

•Rebuilding automaticity – through well-timed and dosed dual tasking

Stages of recovery (5)Stage 5: Full-contact practice or full dynamics at work

Normal and full-speed training activities, meetings, task completion

Restore confidence and assess game or work readiness

Psychology of return (employer, coach, player, team, parent)

Set expectations for employee/player rotation, rest breaks

Consider pressure situations, player strengths

Ensure that work or game-level exertion does not provoke symptoms

Prevention

Equipment

Neck strengthening

Education

Rules changes

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Prevention Equipment: There is no evidence to support the use of helmets or mouth guards for prevention of concussion; (131) however, to reduce the risk of more severe brain injury, dental injury, and facial injury, the use of helmets, mouth guards and facial protection is recommended.

Neck strengthening: Strength of the muscles of the neck and posterior shoulders has the potential to moderate acceleration/deceleration forces during direct or indirect head trauma. Neck strength was a significant predictor of concussion, where every 1-lb increase in neck strength decreased the odds of having a concussion by 5%.

Prevention Education: Increased importance on getting the player assessed immediately; reduced stigma; improved officiating education.

Rules changes:

Attempts are being made to reduce inherent penalties for removing a player, allowing for time to assess and rule-in/out a concussion

Some of the most dangerous plays/moves are being more penalized

Automatic removal for: helmet coming off and other preventions

Case studies

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Standardized exertion “dosage”

Dual tasking with agility

Summary statistics and facts…

•Prior history of concussion appears to be associated with increased concussion risk, more severe presentation, and a protracted recovery course following subsequent concussion.

•In sports with similar rules (eg, soccer, basketball, softball, baseball), women sustain concussion at rates significantly higher than men do.

•High school athletes take longer to recover from a concussion than do collegiate athletes.

•Athletes with posttraumatic migraines show greater cognitive impairment and are more likely to have a more protracted recovery following concussion.

•The presence of psychiatric disorders has been associated with worse outcomes following concussion in several studies.

•Patients with history of learning disability had protracted recovery following mTBI, and presence of attention deficit hyperactivity disorder (ADHD) may be associated with greater risk of concussion.

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Summary statistics and facts (continued)…

•Brief LOC does not appear to be related to recovery following concussion.

•Presence of amnesia may be associated with symptoms at 3 days postinjury, with retrograde more predictive than anterograde (posttraumatic) amnesia. However, amnesia might not be related to prolonged (<3 wk) recovery.

•As an acute (on-field) symptom, dizziness has been shown to be strongly associated with prolonged recovery after concussion. When present at 1 or 2 weeks after injury, dizziness appears to be predictive for development of persistent PCS.

•Patients reporting the symptom of fogginess postinjury appear to have a more severe and protracted recovery course.

•Cognitive deficits in the first few days (<3 d) following concussion are predictive of more complicated and prolonged recovery. This effect appears magnified when more areas of cognitive function are involved.

Questions?

Contact information

Mike Studer, PT, MHS, NCS, CEEAA, CWT, CSST

mike@northwestrehab.com

Facebook: NWRehab

www.northwestrehab.com

YouTube:PhysicalTherapyNWRA

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References + evidence1. Prolonged Activity Restriction After Concussion: Are We Worsening Outcomes? DiFazio M, Silverberg ND, Kirkwood MW, Bernier R, Iverson GL. Clin Pediatr (Phila). 2015 Jun 29

2.Sports-Related Concussion. Laker SR Curr Pain Headache Rep. 2015 Aug;19(8):510.

3.Detecting Migraine in Patients with Mild Traumatic Brain Injury Using Three Different Headache Measures. Anderson K, Tinawi S, Lamoureux J, Feyz M, de Guise E. Behav Neurol. 2015

4.Factors Associated With Problems for Adolescents Returning to the Classroom After Sport-Related Concussion. Baker JG, Leddy JJ, Darling SR, Rieger BP, Mashtare TL, Sharma T, Willer BS. Clin Pediatr (Phila). 2015 Jun 17

References + evidence5.Cognitive Improvement after Mild Traumatic Brain Injury Measured with

Functional Neuroimaging during the Acute Period. Wylie GR, Freeman K, Thomas A, Shpaner M, OKeefe M, Watts R, Naylor MR. PLoS One. 2015 May 11;10(5)

6.Gender and age predict outcomes of cognitive, balance and vision testing in a multidisciplinary concussion center. Benedict PA, Baner NV, Harrold GK, Moehringer N, Hasanaj L, Serrano LP, Sproul M, Pagnotta G, Cardone DA, Flanagan SR, Rucker J, Galetta SL, Balcer LJ. J Neurol Sci. 2015 Jun 15;353(1-2):111-5

7.Return-to-play: a primary care physician's guide to management. List M, Nolz Z, Nord W, Huntington M. S D Med. 2015 Mar;68(3):121-3, 125. Review.

8. The relationship between adherence behaviors and recovery time in adolescents after a sports-related concussion: an observational study. Moor HM, Eisenhauer RC, Killian KD, Proudfoot N, Henriques AA, Congeni JA, Reneker JC. Int J Sports Phys Ther. 2015 Apr;10(2):225-33.

References + evidence9. Repetitive concussions in adolescent athletes - translating clinical and experimental research into

perspectives on rehabilitation strategies. Semple BD, Lee S, Sadjadi R, Fritz N, Carlson J, Griep C, Ho V, Jang P, Lamb A, Popolizio B, Saini S, Bazarian JJ, Prins ML, Ferriero DM, Basso DM, Noble-Haeusslein LJ. Front Neurol. 2015 Apr 2;6:69.

10. Exertion Testing in Youth with Mild Traumatic Brain Injury/Concussion. DeMatteo C, Volterman KA, Breithaupt PG, Claridge EA, Adamich J, Timmons BW. Med Sci Sports Exerc. 2015 Apr 11.

11. Current and emerging rehabilitation for concussion: a review of the evidence. Broglio SP, Collins MW, Williams RM, Mucha A, Kontos AP. Clin Sports Med. 2015 Apr;34(2):213-31.

12. Diagnosis, prognosis, and clinical management of mild traumatic brain injury. Levin HS, Diaz-Arrastia RR. Lancet Neurol. 2015 May;14(5):506-17.

13. Clinical correlates of retrograde amnesia in mild traumatic brain injury. Luoto TM, Iverson GL, Losoi H, Wäljas M, Tenovuo O, Kataja A, Brander A, Öhman J. Brain Inj. 2015;29(5):565-72.

14. Expert consensus document: Mind the gaps—advancing research into short-term and long-term neuropsychological outcomes of youth sports-related concussions. Carman AJ, Ferguson R, Cantu R, Comstock RD, Dacks PA, DeKosky ST, Gandy S, Gilbert J, Gilliland C, Gioia G, Giza C, Greicius M, Hainline B, Hayes RL, Hendrix J, Jordan B, Kovach J, Lane RF, Mannix R, Murray T, Seifert T, Shineman DW, Warren E, Wilde E, Willard H, Fillit HM. Nat Rev Neurol. 2015 Apr;11(4):230-44.

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References + evidence15. A review of the neuro- and systemic inflammatory responses in post concussion symptoms:

Introduction of the "post-inflammatory brain syndrome" PIBS. Rathbone AT, Tharmaradinam S, Jiang S, Rathbone MP, Kumbhare DA. Brain Behav Immun. 2015 May;46:1-16.

16. A pilot study of active rehabilitation for adolescents who are slow to recover from sport-related concussion. Gagnon I, Grilli L, Friedman D, Iverson GL. Scand J Med Sci Sports. 2015 Mar 3.

17.Relationship Between Cognitive Assessment and Balance Measures in Adolescents Referred for Vestibular Physical Therapy After Concussion. Alsalaheen BA, Whitney SL, Marchetti GF, Furman JM, Kontos AP, Collins MW, Sparto PJ. Clin J Sport Med. 2015 Feb 10.

18.Mild traumatic brain injury. Katz DI, Cohen SI, Alexander MP. Handb Clin Neurol. 2015;127:131-56.

19.Changes in symptoms in concussed and non-concussed athletes following neuropsychological assessment. Meyer JE, Arnett PA. Dev Neuropsychol. 2015 Jan;40(1):24-8.

20.Occipital neuralgia as a sequela of sports concussion: a case series and review of the literature. Zaremski JL, Herman DC, Clugston JR, Hurley RW, Ahn AH. Curr Sports Med Rep. 2015 Jan;14(1):16-9.

21.High school principals' resources, knowledge, and practices regarding the returning student with concussion. Heyer GL, Weber KD, Rose SC, Perkins SQ, Schmittauer CE. J Pediatr. 2015 Mar;166(3):594-9.

References + evidence22.Effects of hyperbaric oxygen on eye tracking abnormalities in males after mild traumatic brain injury.

Cifu DX, Hoke KW, Wetzel PA, Wares JR, Gitchel G, Carne W. J Rehabil Res Dev. 2014;51(7):1047-56.

23. Evaluation and treatment of the concussed athlete – update.Kaufman MS, Concannon LG, Herring SA. Phys Med Rehabil Clin N Am. 2014 Nov;25(4):707-22.

24.Knowledge of paediatric concussion among front-lineprimary care providers. Zemek R, Eady K, Moreau K, Farion KJ, Solomon B, Weiser M, Dematteo C.Paediatr Child Health. 2014 Nov;19(9):475-80.

25.McClincy MP, Lovell MR, Pardini J, Collins MW, Spore MK. Recovery from sports concussion in high school and collegiate athletes. Brain Inj. 2006;20(1):33-39.)

26.Collins M, Lovell MR, Iverson GL, Ide T, Maroon J. Examining concussion rates and return to play in high school football players wearing newer helmet technology: a three-year prospective cohort study. Neurosurgery. 2006;58(2):275-286.

27.Iverson GL, Brooks BL, Collins MW, Lovell MR. Tracking neuropsychological recovery following concussion in sport. Brain Inj. 2006;20(3):245-252.

28. McCrea M, Guskiewicz KM, Marshall SW, et al. Acute effects and recovery time following concussion in collegiate football players: the NCAA concussion study. JAMA. 2003;290(19):2556-2563.

*Spontaneous recovery occurs within 10 to 21 days for 80% to 90% of athletes following sport-related concussion.

DUAL TASK References 1.Dual-Task Tandem Gait and Average Walking Speed in Healthy Collegiate Athletes.Howell DR, Oldham JR, Meehan WP 3rd, DiFabio MS, Buckley TA.Clin J Sport Med. 2017 Oct 5

2.The utility of instrumented dual-task gait and tablet-based neurocognitive measurements after concussion.Howell DR, Stillman A, Buckley TA, Berkstresser B, Wang F, Meehan WP 3rd.J Sci Med Sport. 2017 Aug 16.

3.The Association between Dual-Task Gait after Concussion and Prolonged Symptom Duration.Howell DR, Brilliant A, Berkstresser B, Wang F, Fraser J, Meehan WP 3rd.J Neurotrauma. 2017 Oct 16.

4.Self-reported balance status is not a reliable indicator of balance performance in adolescents at one-month post-concussion.Rochefort C, Walters-Stewart C, Aglipay M, Barrowman N, Zemek R, Sveistrup H.J Sci Med Sport. 2017 Nov;20(11):970-975.

5.Single-task and dual-task tandem gait test performance after concussion.Howell DR, Osternig LR, Chou LS.J Sci Med Sport. 2017 Jul;20(7):622-626.

6.Single-Task and Dual-Task Gait Among Collegiate Athletes of Different Sport Classifications: Implications for Concussion Management.Howell DR, Oldham JR, DiFabio M, Vallabhajosula S, Hall EE, Ketcham CJ, Meehan WP 3rd, Buckley TA.J Appl Biomech. 2017 Feb;33(1):24-31.